Vulnerable 'girls knee' cries out for preventative measures

First the run-up, she’s going faster and faster. There's the springboard. There she goes, into the air. Flight elements, landing. A jump like she’s done a hundred times before without a problem. This time it goes wrong. Anne Benjaminse hears a snap. ‘I can still remember the pain in my knee, more than twenty years later.’

_{Tekst Riepko Buikema}

The then student of Physiotherapy was in her early twenties when she tore her anterior cruciate ligament while practising gymnastics. In one of those silly moments at the end of practice. ‘I was tired. And perhaps a bit nonchalant.’ In an instant, her gymnastics career was over. ‘As a little girl, I loved doing it – loved working out my entire body and perfecting my exercises.’

Expert in cruciate ligament injuries

Without realizing it, the injury forms the first step toward her current mission. Benjaminse is writing a thesis on cruciate ligament injuries, completing a Master’s in Sports Medicine at the University of Pittsburgh, and doing a PhD in Groningen with movement scientists Bert Otten and Koen Lemmink. The anterior cruciate ligament is still her guideline, even though she has moved her attention to a different sport. Nowadays, Benjaminse has set herself up as guardian of the female football knee and not without reason.

Female footballers often unlucky

According to Edwin Goedhart, Manager of Sports Medicine at the Dutch national football association KNVB, our country should expect a boom in cruciate ligament injuries because of the growing group of football-playing adolescent girls. The chance of suffering a cruciate ligament injury is four to eight times higher for girls than for boys. And those who suffer from it are usually twice unlucky: one in four women tear their anterior cruciate ligament a second time, often in the other knee.

This is partly due to women’s anatomy and partly because female leg muscles are naturally less strong than those of males. Add to that the fact that, around the ovulation, hormones loosen the female ligaments, that shoes and types of exercise are often based on the male body, and that girls probably deal with complex situations on the field differently than boys. ‘And teenage girls have a lot going on. It’s the phase where they have their first romantic relationships. They’re suddenly a lot taller, or they have to deal with an annoying maths teacher, or a failed exam. That influences how you feel when you’re standing on the field on Saturday.’

Long and boring excercises

It almost sounds like an appeal: mothers and fathers, keep your football-playing daughters inside! That is the opposite of what Benjaminse is trying to achieve. The scientist sees opportunities to prevent cruciate ligament injuries and wants to make coaches aware of them. ‘Coaches should pay more attention to prevention. They could spend more time on broad motor development, for example by doing varied warm-up exercises. That is what’s lacking now. Many clubs do ‘dry’ strength exercises, such as planking or lunges. Oftentimes, these last too long or are too boring, and they don’t do justice to match situations. Prevention is not just about strength but mostly about coordination: about recognizing situations and knowing how to anticipate and respond to them. How do you deal with an opponent’s attack or feint? When do you or do you not engage in a duel? So far, this link in the brain between perception and action receives little to no attention in prevention.’

FC Groningen ladies come to the rescue

In collaboration with talented female FC Groningen players, Benjaminse and her team are developing prevention exercises specifically for teenage football-playing girls. These exercises pay extra attention to defensive actions, which often cause knee injuries. A good example of this is the injury of Dutch international and star striker Vivianne Miedema (see also this video). ‘No opponent is actually near her, she stretched for a ball and – Benjaminse snaps her fingers – it’s already happened.'

Benjaminse is practising how to anticipate and respond to opponents’ feints with young female football players. She adjusts exercises they were already doing during practice anyway, so it does not take more time. These exercises are not just about the competitive objective – are you able to steal the ball – but also, and more importantly, about how a player moves. ‘Does her knee remain above her foot well enough? Does she bend her knees far enough upon landing to cushion her weight?’

Don't prescribe everything

To deeply imprint the correct movement in the players’ minds, it is important for coaches to make their directions as visual as possible. ‘We are often inclined to describe everything explicitly: bend your knee, twist your torso. But the pivot is to let the players learn through implicit motor learning, for example by saying: pretend that you are sitting on a chair. Our research shows that female football players then perform the movement increasingly better and without thinking.’

By practising match situations, in numerous variations, female football players build a repertoire of optimal movements. ‘Coaches already have a lot on their minds, I realize that. But, ideally, our exercises will be taught in the coaching training programme, either in the regular programme or, alternatively, as an extra module in continuing education. Edwin Goedhart, the KNVB’s sports doctor, wholly agrees.’

Time for a change

‘I feel a great sense of responsibility, Because girls’ football is growing and, at the moment, little to no attention is paid to prevention, or only in a very outdated manner. The young football girls are a neglected group. Research studies tend to look at boys and men, and at adults. I think it’s important that everyone can enjoy doing sports for as long as possible, including these teenage girls with their vulnerable knees.’

More information

• Benjaminse in NOS Sport

• Benjaminse in het Jeugdjournaal (the Children’s News)

• Benjaminse on LinkedIn